Provider Demographics
NPI:1972235992
Name:BUCCAL UP DENTAL OLATHE LLC
Entity type:Organization
Organization Name:BUCCAL UP DENTAL OLATHE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-960-3070
Mailing Address - Street 1:5314 S YALE AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-6271
Mailing Address - Country:US
Mailing Address - Phone:918-960-3070
Mailing Address - Fax:539-867-1236
Practice Address - Street 1:11132 S LONE ELM RD
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-9434
Practice Address - Country:US
Practice Address - Phone:913-780-0123
Practice Address - Fax:913-829-9510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1376521765OtherNPI